Complications following curative brain arteriovenous embolization: a 12-year single-center cohort study with MRI-monitored adverse events

OBJECTIVE Advancements in endovascular devices and techniques have improved cure rates for selected brain arteriovenous malformations (AVMs). However, data on angiographic and treatment-related complications remain limited. This study presents a 12-year single-center experience with curative endovascular treatment (EVT), along with comparative insights from previously published cohorts. METHODS Data from all brain AVMs treated with curative intent EVT between 2010 and 2022 were reviewed for baseline demographic characteristics, angioarchitectural features, treatment techniques (single arterial, double arterial, venous, arterial and venous, and transvenous embolization with selective temporary flow arrest [TFATVE]), complications, and clinical and angiographic outcomes. Hemorrhagic and ischemic complications were assessed with postprocedural MRI. Ischemic volumes were semiautomatically calculated on apparent diffusion coefficient maps using regions of interest segmentation by two independent readers. Univariate and multivariate analyses were performed to identify predictors of cure and complications. RESULTS A total of 193 patients (54% male, mean ± SD age 38.7 ± 15.9 years) with 193 AVMs (60.6% ruptured) were included. The following techniques were included: single arterial (37.8%), double arterial (26.4%), arterial and venous (19.7%), TFATVE (8.3%), and single venous (7.8%). Intraprocedural complications occurred in 10.4% of cases. Both hemorrhagic and symptomatic ischemic complications occurred in 15.5% of patients. Mean ischemic volume was 9.4 ± 15.1 cm 3 and was significantly higher in symptomatic cases. Overall minor and major complications rates were 14% and 3.1%, respectively. The mortality rate was 4.7% and was lower in unruptured AVMs though these had a higher complication rate. The overall angiographic cure rate was 80.3%, increasing to 93%–100% in cases treated with advanced approaches. On multivariate analysis, AVM in an eloquent brain location was associated with lower cure rates (OR 0.3, p = 0.023), while advanced techniques involving TVE were associated with higher cure rates (OR 7.9, p < 0.001). CONCLUSIONS This large, single-center experience adds to the growing evidence that curative EVT can be a valuable option, especially when advanced techniques are used for low-grade and ruptured deep AVMs. At the same time, higher complication rates in unruptured or higher grade (Spetzler-Martin [SM] grade IV–V) lesions highlight the importance of cautious patient selection. Larger, multicenter prospective studies in high-volume centers are needed to better define the role of curative EVT.